1790714772 NPI number — MR. CARLOS DESIR JR. CRNA

Table of content: MR. CARLOS DESIR JR. CRNA (NPI 1790714772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790714772 NPI number — MR. CARLOS DESIR JR. CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESIR
Provider First Name:
CARLOS
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790714772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1108 CERRITO BAJO LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79912-2055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-526-6280
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 ALBERTA AVE
Provider Second Line Business Practice Location Address:
STE. 101
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79905-2709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-545-6550
Provider Business Practice Location Address Fax Number:
915-545-6984
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  APRN11014152 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 0024178638 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 715008 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 178511501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85416U . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 455050056 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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